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Tactical Medicine Training for SEAL Mission Commanders

14 July 2000

Frank K. Butler, Jr

CAPT MC USN

Director of Biomedical Research

Naval Special Warfare Command

The opinions and assertions expressed by the author are his alone and do
not necessarily reflect the views of the Departments of the Navy or Defense.

Abstract

The Tactical Combat Casualty Care (TCCC) project initiated by Naval
Special Warfare and continued by the U.S. Special Operations Command has
developed a new set of combat trauma care guidelines that seek to combine good
medical care with good small-unit tactics. The principles of care recommended
in TCCC have gained increasing acceptance throughout the Department of Defense
in the four years since their publication and increasing numbers of combat
medical personnel and military physicians have been trained in this concept.
Since casualty scenarios in small-unit operations typically present tactical as
well as medical problems, however, it has become apparent that a customized
version of this course suitable for small-unit mission commanders is a
necessary addition to the program. This paper describes the development of a
course in Tactical Medicine for SEAL Mission Commanders and its transition into
use in the Naval Special Warfare community.

Introduction

In the past, combat trauma training for Special Operations corpsmen,
medics, and pararescuemen (PJs) was based on the principles taught in the
Advanced Trauma Life Support (ATLS) Course. (1) ATLS is a standardized approach
to trauma care that was developed by the Committee on Trauma of the American
College of Surgeons. It is revised every 4 years and is widely accepted in the
United States. ATLS is considered the standard of care for the Emergency
Department management of trauma patients in both civilian and military
hospitals. If one undertakes to use this course to train combat medical
personnel, however, it quickly becomes apparent that ATLS was not designed to
be used in the combat environment. ATLS was developed for physicians, not for
combat medics. It assumes that hospital diagnostic and therapeutic equipment is
available and, most importantly, does not recognize the existence of the
tactical combat environment. There is no provision or allowance for such
factors as incoming fire, darkness, environmental factors (the casualty may
occur in a swamp, in the snow, or in the surf zone), casualty transportation
problems, long delays to definitive care, and the need to balance the
management of casualties with the conduct of an ongoing combat mission.
Therapeutic measures that are taken for granted in the emergency department,
such as CPR, c-spine immobilization, endotracheal intubation, starting two
large-bore IVs, insertion of nasogastric tubes and foley catheters,
supplemental oxygen therapy, and the complete undressing of the patient to
complete a secondary survey would be inappropriate in the middle of an ongoing
firefight. This is not a criticism of ATLS, rather, it is a reflection of the
fact that those of us in military medicine were trying to use ATLS in a setting
for which it was not intended.

This realization, however, leaves us with a question. If an approach to
battlefield trauma care other than ATLS is to be used, what should it be?
Combat medical personnel are expected to make appropriate adjustments to
civilian trauma guidelines on the battlefield, but why wait until they are in
the middle of a firefight to begin thinking about what these adjustments should
be? Corpsmen and medics must be aware of the fact that good medicine can
sometimes be bad tactics and that bad tactics can get everyone killed or cause
the mission to fail. Casualty scenarios in Special Operations usually entail
both a medical problem and a tactical problem, and we want the best possible
outcome for both the man and the mission. This realization forces us to
redefine our outcome measures for the management of trauma in combat as shown
in the TCCC Objectives in Figure 1.

In 1993, the Naval Special Warfare Command established a formal
requirement to review the management of combat trauma in the tactical Special
Warfare environment and make recommendations for changes as appropriate. The
research approach used was to do a preliminary literature review and establish
an initial set of recommendations. The recommendations were then reviewed over
a six-month period in meetings with Special Operations corpsmen, medics, and
physicians and consensus opinions were developed. Draft copies of the paper
were then sent out to approximately 30 subject matter experts in the fields of
emergency medicine, general and trauma surgery, critical care medicine,
anesthesiology and cardiothoracic surgery. The paper was again revised to
incorporate changes recommended by these reviewers and subsequently published
as a Supplement to Military Medicine. (2) The approach used was intended to
ensure that the TCCC guidelines had as much input as possible from combat
corpsmen and medics.

TCCC Transition

Some of the recommendations made in the TCCC guidelines were
controversial when initially published. The Naval Special Warfare community and
the U.S. Special Operations Command, which had by this time assumed
administrative control of the research program, were faced with the problem of
how to transition the TCCC concepts into use. This aspect of the project was
critically important. Without a successful transition effort, the research
would have been of no help to SOF combat units.

Preliminary concept approval was first obtained from the Commander of
the Naval Special Warfare Command. The next step in the process was to take it
to the Bureau of Medicine and Surgery (BUMED). Initial BUMED contact was with
CAPT Bob Hufstader, then Deputy Chief of the Medical Corps, who proposed that
the best way to approach BUMED evaluation was to determine specifically which
courses TCCC should be taught in and to seek out the individuals responsible
for teaching that course. This was accomplished and, in March 1996, TCCC
training was incorporated into the Undersea Medical Officer (UMO) training
course in Groton, Connecticut, which is responsible for training the UMOs who
support SEAL units. After this action had been taken, final approval of this
concept was approved from the Commander of the Naval Special Warfare Command.
In his letter of 9 April 1997, (3) RADM Tom Richards directed that the TCCC
guidelines as outlined in reference (2) be used as the standard of care for the
tactical management of combat trauma in Naval Special Warfare.

A six-hour TCCC course for SEAL corpsmen was developed, approved by
BUMED, and taught to all SEAL corpsmen beginning in April of 1997. This course
was designed to supplement the extensive trauma training received by SEAL
corpsmen at the Joint Special Operations Medical Training Center (JSOMTC). The
JSOMTC has now added the TCCC course to its curriculum. The principles of TCCC
as taught in this course have also been adopted at least in part by the USAF
(4), the US Army (personal communication, COL Richard Shipley, Commander of the
US Army Academy of Health Sciences), the Israeli Defense Force (5), the US Army
Special Forces (6), and the US Marine Corps. The TCCC course was taught at the
Field Medical Service School at Camp Pendleton for the first time in February
2000.

Perhaps the most important milestone in the transition process was the
inclusion of the TCCC guidelines in the Prehospital Trauma Life Support Manual.
(7) The fourth edition of this manual, published in 1999, contains, for the
first time a chapter on military medicine. Preparation of this chapter was
coordinated by CAPT Greg Adkisson and COL Steve Yevich of the Defense Medical
Readiness Training Institute in San Antonio, Texas. The recommendations
contained in the PHTLS Manual carry the endorsement of the American College of
Surgeons Committee on Trauma and the National Association of EMTs. The
TCCC guidelines are the only set of battlefield trauma guidelines ever to have
received this dual endorsement

Although the TCCC protocol is gaining increasing acceptance throughout
the U.S. Department of Defense and allied military forces, this protocol by
itself is not adequate training for the management of combat trauma in the
tactical environment. Since casualty scenarios in small-unit operations entail
tactical problems as well as medical ones, the appropriate management plan for
a particular casualty must be developed with an appreciation for the entire
tactical situation at hand. (2) This approach has been developed through a
series of workshops carried out by SOF medical personnel in association with
appropriate medical specialty groups such as the Undersea and Hyperbaric
Medical Society, the Wilderness Medical Society, and the Special Operations
Medical Association. (8-10) The most recent workshop, which addressed the
Tactical Management of Urban Warfare Casualties in Special Operations, noted
that several of the casualty scenarios studied from the Mogadishu action in
1993 (10,11) had very important tactical implications for the mission
commanders. The unconscious fast-rope fall victim in the first scenario
resulted in a decision by the mission commander to split the forces in his
ground convoy, detaching 3 of the 12 vehicles to take the casualty back to base
immediately, leaving the remaining 9 to extract the rest of the troops. The
helicopter crash described in Scenario 2 resulted in the pilots body
being trapped in the wreck. As several discrete elements from the target
building moved towards the crash site to assist, as described in Scenarios 5
and 6, they suffered multiple casualties. The casualties eventually outnumbered
those who were able to maneuver, forcing the elements to remain stationary and
preventing them from consolidating their forces. When a rescue convoy finally
reached the embattled troops at the crash site, there was a delay of
approximately 3 hours while the force worked feverishly to free the trapped
body. Several hundred troops and over 25 vehicles were vulnerable to
counterattack during this period. These scenarios made it obvious to members of
the workshop panel that training only combat medics in tactical medicine is not
enough. If tactical medicine involves complex decisions about both tactics and
medicine, then we must train the tactical decision-makers  the mission
commanders - as well as combat medical personnel in this area. (10) This paper
is a description of how that has been accomplished in the Naval Special Warfare
community.

The Tactical Medicine for SEAL Mission Commanders Course

The concept of medical training for Special Operations combat operators
is not new, but in the past, this training has usually focused on skills rather
than strategies. The operators were trained to start IVs, apply field
dressings, and so forth. This training is important, but needs to be
supplemented by a strategies approach to combat medicine. A Tactical Medicine
for SEAL Mission Commanders Course was developed to meet this need. The course
is currently comprised of 5 main sections:

a background of the Tactical Combat Casualty Care initiative

an explanation of the need to train mission commanders in this area

a description of how people die in ground combat

the TCCC guidelines for Care Under Fire and Tactical Field Care

an introduction to scenario-based training and planning

The background of the TCCC concept is presented as described above. The
remaining aspects of the course are outlined below.

Why Train Mission Commanders in Tactical Medicine?

The Tactical Medicine course as taught in Naval Special Warfare provides
a rationale for why mission commanders need training in this area. While it is
true that corpsman usually takes care of the casualty, the mission commander
runs the mission and what is best for the casualty and what is best for
the mission may be in direct conflict. The question is often not just
whether or not the mission can be completed successfully without the wounded
individual(s); the issue may well be that continuing the mission may adversely
affect their outcome for the casualty. If the mission is to be successfully
accomplished, the mission commander may have to make some very difficult
decisions about the care and movement of casualties. RADM Eric Olson, in his
comments at the Urban Warfare workshop, points out that one of the primary
responsibilities of the individual providing medical care is not to hinder the
mission commander in the overall execution of the mission. (10) Additional
reasons to train SEAL mission commanders in tactical medicine include: 1) the
importance of having the commander know that the care provided in TCCC may be
substantially different than the care provided for the same injury in a
non-combat setting; 2) the unit may be employed in such a way that there is no
corpsman, medic, or PJ immediately available to the injured individual; and 3)
the corpsman, medic or PJ may be the first team member shot.

How People Die in Ground Combat

This portion of the course was adopted from a presentation given by COL
Ron Bellamy to the Joint Health Services Support Vision 2010 working group.
(17) It is critically important that mission commanders be aware that the
individuals with the most severe wounds are not necessarily the ones who should
be treated first. The definitions of KIA (Killed in Action) versus DOW (Died of
Wounds) are explained. The mission commanders are then presented with the
percentages shown in Figure 2. These numbers are accompanied by a series of
photographs illustrating the various types of fatal injuries. The point is made
that for a through-and-through head wound with massive brain damage, even if
the most skilled neurosurgeon in the world were present with the unit on the
battlefield, there would be little that he or she could do to successfully
intervene. By describing how casualties die, the course attendees gain a basic
understanding of what might be done to prevent death and a more realistic set
of expectations for the care which will be rendered by his combat medical
personnel. An understanding which deaths are avoidable is enhanced by
emphasizing COL Bellamys important concept of focusing on the causes of
preventable death on the battlefield. These are summarized in Figure 3.
Air warfare, combat swimmer missions, shipboard warfare, and other types of
combat would, of course, be expected to have different injury patterns.

Basic Combat Trauma Management Plan

The three phases of care proposed in the TCCC paper (2) are shown in
Figure 4. Care under Fire is defined as the care rendered by the
medic or corpsman at the scene of the injury, while he and the casualty are
still under effective hostile fire. The available medical equipment is limited
to that carried by the individual operator or by the corpsman, PJ, or medic in
his medical pack. Tactical Field Care" is the care rendered by the
corpsman, PJ, or medic once the unit is no longer under effective hostile fire.
This term also applies to situations in which an injury has occurred on a
mission, but there has there has been no hostile fire. The available medical
equipment is still limited to that carried into the field by mission personnel.
Time prior to evacuation to an MTF is very variable. "Combat Casualty
Evacuation Care" or CASEVAC care is the care rendered once the
casualty (and usually the rest of the mission personnel) have been picked up by
a aircraft, vehicle, or boat. Personnel and medical equipment that may have
been previously staged in these assets will now be available.

Care under Fire

Once these terms have been reviewed, the protocol outlined for the Care
under Fire phase as shown in Figure 5 is presented and discussed. The care in
this phase is the same as outlined in reference (2) except for the important
added recommendation that the casualty continue to return fire if able to do so
effectively. This change from the original protocol was proposed by then-CDR
Pat Toohey, Commanding Officer of SEAL Team Four. It is very much in keeping
with the philosophy noted in the original paper that the best medicine on
the battlefield is fire superiority. The fact that control of
hemorrhage is the top priority is emphasized by pointing out that
exsanguination from extremity wounds is the number one cause of preventable
death on the battlefield. Hemorrhage from extremity wounds was the cause of
death in more than 2500 casualties in Vietnam who had no other injuries. (12)

Although tourniquets are discouraged by ATLS, they are believed to be
the most reasonable initial choice to stop potentially life-threatening
bleeding in the Care under Fire Phase because of the need to stop the bleeding
immediately and definitively. Direct pressure is hard to maintain during the
casualty transportation that will hopefully follow this phase of care. The
following points are emphasized about tourniquets: 1) damage to the extremity
is rare if the tourniquet is left in place less than an hour; 2) tourniquets
are often left in place for several hours during surgical procedures; 3) in the
face of massive extremity hemorrhage, in any event, it is better to accept the
small risk of ischemic damage to the limb than to lose a casualty to
exsanguination; 4) both the casualty and the corpsman/medic are in grave danger
while a tourniquet is being applied during the Care under Fire phase, so
non-life threatening bleeding should be ignored until the Tactical Field Care
phase; 5) the decision regarding the relative risk of further injury versus
that of exsanguination must be made by the corpsman/medic rendering care; 6) if
applied, the tourniquet should be applied as close to bleeding site as
possible; 7) the time of application should be noted; and 8) they should be
removed when feasible. The need for immediate access to a tourniquet in such
situations makes it clear that all SOF operators on combat missions
should have a suitable tourniquet readily available at a standard location on
their battle gear and be trained in its use. (2,3) Mission commanders
are reminded that since this is an equipment item for every man in the unit, it
is the mission commanders responsibility to ensure that a tourniquet is
part of the routine pre-mission equipment check. As a final point of emphasis,
the story of the death of General Albert Sidney Johnston at Shiloh on 7 April
1862 is presented. (13) General Johnston was one of the senior commanders in
General Robert E. Lees army. His command surgeon, Dr. David Yandell, had
directed that tourniquets be issued to the troops prior to the battle. During
the battle, General Johnston sustained a fatal hemorrhage from a popliteal
artery injury that presumably could have been controlled by a tourniquet. The
General forgot that he had one available and bled to death with his tourniquet
in his pocket.

Since some of the mission commanders may have had some basic medical
training, a few other major points of departure from civilian care are
emphasized. Does the cervical spine not need to be immobilized before moving a
trauma patient with a head or neck injury? The findings of Arishita et al (15)
answer this question convincingly. They reviewed the issue of cervical spine
immobilization (CSI) in penetrating neck injuries in Vietnam and found that in
only 1.4% of patients with penetrating neck injuries would CSI have been of
possible benefit. Time to accomplish CSI was found to be 5.5 minutes, even with
experienced EMTs. Their conclusion was that potential hazards to both patient
and provider in a combat environment outweighed the potential benefit of CSI
for penetrating neck injuries. The distinction between penetrating trauma and
blunt trauma is reviewed, since parachuting injuries, fast-roping injuries,
falls, and other types of trauma resulting in neck pain or unconsciousness
should be treated with CSI unless the danger of hostile fire constitutes a
greater risk in the judgement of the treating corpsman, PJ, or medic.

The difficulties of casualty transportation in the Care under Fire phase
are reviewed. Senior combat medical personnel point out that this is often the
most problematic aspect of care. Standard litters for patient transport are not
carried into the field on many direct action Special Operations missions
because of weight and bulk. Transport of the patient is accomplished with a
shoulder carry or improvised litter. This works reasonably well when the
casualty weighs 150 pounds and the rescuer weighs 250 pounds, less well when
the roles are reversed. The need to rotate personnel carrying a casualty during
an extraction is pointed out.

Tactical Field Care

The outline of Tactical Field Care as shown in Figure 6 is presented.
The Mission Commanders course omits much of the medical literature discussion
contained in the longer (6-hour) BUMED-approved course taught to SEAL corpsmen.

The second major change from the protocol presented in reference (2)
deals with the fluid resuscitation of patients with penetrating trauma of the
chest or abdomen who are losing consciousness. Several such casualties were
discussed at the workshop on urban warfare casualties workshop.(10) There was a
clear consensus in the expert panel that should a casualty with uncontrolled
hemorrhage have mental status changes or become unconscious (blood pressure of
50 systolic or below), he should be given either an empiric bolus of 1000cc of
Hespan or enough fluid to resuscitate him to an end point of improved mentation
(systolic blood pressure of 70 or above.)

One of the comments made by a senior Naval Special Warfare medical
officer who was asked to review this course was that mission commanders needed
to have an idea of the relative urgency of the various elements of care that
might be required in the Tactical Field Care phase. (personal communication,
CDR Bobby Lowe) A Tactical Field Care battlefield triage plan was added and is
shown in Figure (7).

CASEVAC Care

The term "CASEVAC" is used to describe this phase instead of the
commonly used term MEDEVAC" because the evacuation may require that the
aircraft or other evacuating asset enter an area where the danger of hostile
fire is imminent. Some aircraft will do this and some wont. The need for
the mission commander to be sure that the evacuating asset will enter a hostile
fire zone is illustrated dramatically by Moore and Galloway in their book
We Were Soldiers Once and Young. (14) During the battle of the Ia
Drang Valley, the first large U.S. ground action in Vietnam, the
11th Air Assault Division made contact and had taken numerous
casualties. The request for helicopter evacuation was made to the designated
MEDEVAC unit, but upon learning that there was a firefight in progress, this
unit declined to perform the evacuation. The casualties were not evacuated
until the 229th Assault Helicopter Battalion, a combat air cavalry
helicopter unit, was contacted, resulting in a significant delay to definitive
care. The book contains a quote from Major Bruce Crandall, the commanding
officer of A company of that unit: The officer commanding the
MEDEVACs looked me up to chew me out for having led his people into a hot
landing zone, and warned me never to do it again. Mission Commanders need
to ensure that their evacuating assets are prepared to fly into contested
areas.

The recommendation in the TCCC care paper to establish Combat Casualty
Transport Teams and use them on CASEVAC assets is also reviewed, since this is
a mission commander planning responsibility.

Future Studies and Possible Changes to TCCC

There are many questions about TCCC that lack definitive answers. Some
of these questions have been identified by the USSOCOM Biomedical Initiatives
Steering Committee as research issues and are being investigated either with
USSOCOM funding or in cooperation with the Army Medical Research and Materiel
Command. These issues include: 1) the impact of CASEVAC delays on casualty
outcome; 2) hypotensive fluid resuscitation strategies in uncontrolled
hemorrhage; 3) comparative resuscitation fluid studies in casualties with
controlled hemorrhage and long delays to surgery; 4) oral antibiotics
(fluoroquinolones) as potential alternatives to IV antibiotics for prophylaxis
in non-abdominal combat wounds; and 5) comparative airway studies in
maxillofacial trauma casualties.

Introduction to Scenario-Based Planning

Despite the large amount of Special Operations time and effort that has
gone into developing a combat-appropriate trauma management plan, the bottom
line remains that no single plan is optimal for all situations. If a proposed
trauma care plan does not work for a specific tactical situation, then for SEAL
corpsmen, it just doesnt work. This realization led to the concept of
scenario-based management plans (2). Scenarios chosen for discussion with
mission commanders are ones that are thought to have a relatively high
probability of occurring, have already occurred, require a difficult
tactical/medical decision, or that require a major departure from standard
civilian practice. For those who might argue that this approach injects an
aspect of defeatism or negativity into mission planning, it is noted that there
are only two times that you can plan for what to do in a tactical casualty
situation  before it happens and after it happens.

Some representative scenarios are presented in Figures 8-15. The
medical and tactical issues to be addressed in most of these scenarios have
been addressed previously (8-10). Figures 8 and 9 are from the The Battle of
Mogadishu on 3 October 1993. This engagement resulted in the most US casualties
in a single firefight since Vietnam (18 dead, 73 wounded). In addition, there
was a delay of 15 hours before the first wounded were evacuated to a Combat
Support Hospital. Starting with scenarios that have already occurred helps to
raise the level of interest in the discussions that ensue. An excellent
recommendation made by COL Cliff Cloonan, the Dean of the Joint Special
Operations Medical Training Center, during the planning for the Urban Warfare
casualties workshop (10) was to use a series of specific questions to focus the
discussion. Incorporating this technique into the training adds greatly to the
quality of the discussion and enhances the power of the scenario-based
technique. For example, the questions asked of the mission commanders in the
first scenario (Figure 8) include:

Should the treating medic shoot first and treat later or should he
treat immediately?

Should the casualty be moved to cover before treating?

Should the medic wait for a long spine board before moving casualty
to cover or should the casualty be moved to cover immediately?

If the casualty should be moved immediately, what is the best
technique for moving him to minimize the risk of spinal cord injury?

Should this casualty have an IV started?

Should the casualty receive immediate fluid resuscitation? If so,
with what and how much?

What will be the expected impact on the outcome for the casualty if
he has to wait 30 minutes for evacuation instead of being evacuated
immediately?

Are there concealment or defensive techniques (smoke, diversions,
etc) that could be used in this scenario?

Are there area denial techniques that could be used effectively in
this scenario? - Helicopter CASEVAC was very difficult because of crowds and
RPGs. Vehicle CASEVAC was a problem because of crowds, roadblocks, RPGs, and
ambushes. What changes need to be made in CASEVAC plans for urban warfare in
the future to address these problems?

Providing adequate gunfire support in this scenario was problematic
because of the presence of buildings that provided cover for hostile forces and
the danger to helicopters from RPG fire. What changes could be made in the
gunfire support plan to make gunfire support more effective?

Figures 10-12 deal with a parachute insertion and subsequent land
warfare phase with injuries of several different magnitudes imposed on landing.
The medical care of these casualties is relatively straightforward, but they
require some difficult tactical decisions by the mission commander which are
discussed.

Figures 13 -15 deal with casualty scenarios that occur during diving
operations. This is a very important aspect of the training for SEAL mission
commanders because the underwater environment has such a large impact on the
management plan and because this area is virtually unaddressed in the civilian
medical literature.

As the group discusses the various scenarios, it becomes apparent that
the appropriate care for a casualty may vary based on: the criticality of the
mission, the anticipated time to evacuation, and the environment in which the
casualty occurs. Any management plan for a combat casualty discussed in the
planning phase should be considered advisory rather than directive in nature,
since only infrequently will an actual tactical situation unfold exactly as
planned.

These scenarios illustrate that the importance of the role of the
mission commander in dealing with casualties is often just as important as that
of the corpsman, since the units emergency action must address both the
medical and the tactical problems at the same time. It is obviously not
possible to plan for every casualty scenario that might be encountered, but
review of several casualty scenarios most appropriate for an impending
operation is a valuable addition to the planning process.

Transition

The concept for the Tactical Medicine for Mission Commanders course was
first presented to the line leadership at the Naval Special Warfare Center,
which is responsible for teaching the SEAL Junior Officer Training Course to
all officer graduates from Basic Underwater Demolition/SEAL training (BUD/S).
The concept was approved, and with the help of the medical staff at the NSWC,
the course has been taught to all officers graduating from BUD/S since April of
1998. It is being taught to SEAL operational units at present. Two recent
innovations have been recommended by SEAL line officers and are in the process
of being implemented. The Director of Training at the Naval Special Warfare
Center stressed the need to provide course attendees with material at the
course that they could use to help implement this training at the unit level
(personnel communication  CDR Adam Curtis). A Tactical Medicine for
Mission Commanders CD has been approved and is in production at the time that
this article is being written. This CD contains the following items:

Tactical Combat Casualty Care Powerpoint Presentations

Tactical Combat Casualty Care in Special Operations

Tactical Medicine for SEAL Mission Commanders

Mogadishu: The Tactical Medicine Lessons Learned

SOF Combat Casualty Scenarios (275)

ASDS (9)

Biological Warfare (20)

Chemical Warfare (20)

Combat Swimmer Operations (18)

Dry Deck Shelter (16)

Foreign Internal Defense (10)

Hydographic Reconnaissance (3)

In-Flight Aviation Casualties (22)

Mogadishu (9)

Parachute Insertion (10)

Radiation Casualties (24)

Rope Insertions (3)

Small Boat Operations (25)

SEAL Delivery Vehicles (5)

Submarine Lockouts (4)

Small Unit Land Warfare (32)

Urban Warfare (20)

Winter and Mountain Warfare (25)

Tactical Combat Casualty Care Workshops and Papers

Tactical Combat Casualty Care in Special Operations

Tactical Management of Diving Casualties in Special Operations

Tactical Management of Wilderness Casualties in Special Operations

Tactical Management of Radiation Casualties in Special Operations

Tactical Management of Biological Warfare Casualties in Special
Operations

Tactical Management of Chemical Warfare Casualties in Special
Operations

Tactical Management of Urban Warfare Casualties in Special
Operations

It is now anticipated that training in Tactical Medicine for Mission
Commanders will be added to the SEAL Tactical Training Course taught to all new
SEALs after graduation from Basic Underwater Demolition/SEAL training.

Although this course has been developed within the SEAL community, it
has great applicability to the other components of SOF (Rangers, Special
Forces, and Air Force Combat Control Teams) as well as to the Marine Corps and
to other conventional forces that conduct small unit operations. Efforts are
ongoing to coordinate with other potential users of this course to demonstrate
the course to them and make course materials available if desired.

The SEAL Tactical Simulator

A parallel concept could be used to help develop responses to tactical
problems of a non-medical nature in SEAL operations. The aviation community
makes extensive use of flight simulators to sharpen pilots responses to
both aircraft emergencies and tactical problems. The SEAL community likewise
makes extensive use of the SEAL Delivery Vehicle (SDV) simulator to train new
SDV pilots and navigators. There is, however, no simulation tool currently
available for non-SDV SEAL operations. The same scenarios used for casualty
discussion can be modified to present tactical problems. Figure 16 describes a
ship attack in which there is an underwater explosion, but the divers have
apparently suffered only middle ear barotrauma and can both continue with the
mission. A number of tactical options may be considered by the senior member of
the swim pair: 1) ignore the possibility of additional charges and continue
with the planned operation; 2) abort the operation and swim away; 3) swim away
from the ship and observe for possible periodicity of the charges; 4) surface
and shoot the individual dropping the charges; 5) descend to the bottom of the
harbor in an attempt to avoid the effects of subsequent blasts; or 6) swim 180
degrees around to the other side of the target ship to try to gain shielding
from the effects of subsequent blasts. Several of these options may be
reasonable; others would be dramatically ill-advised.

Use of scenario-based casualty planning has led to a number of medical
research projects designed to address unanswered questions or shortcomings in
medical technology. The same thing might occur using tactical scenarios. For
example, if the prisoner in Figure 17 is released, he might compromise the
mission and endanger the lives of mission personnel. If he is restrained at the
location of the contact, there would be no way to release him after the mission
is complete without returning to that location before extraction. One
reasonable option might be to develop a pair of time-release handcuffs that
will allow the prisoner to be restrained and left at the contact site but
released after a preset time.

Use of real-world events would add a valuable measure of realism to the
training obtained with the STS. Figure 18 describes a real-world Special
Operation  the rescue of the Air France 139 hostages at the Entebbe
airport by Israeli commandos in 1976. (16) All of the details of the scenario
are historically correct up to the final line, which describes the first door
entered as being booby-trapped and asks how the leaders of the second and third
elements should change their tactics as a result. If they choose to enter
through their doors as planned, there is a very reasonable expectation that
these doors will be booby-trapped as well, more commandos will be killed, and
all the hostages executed. Looking for roof entrances or other similar
maneuvers would take too much time. The best choice might be for the second and
third elements to enter the terminal through the first door since that booby
trap has already been tripped. Another good choice might be a window entry if
there are suitable windows present. The chilling account of the rescue attempt
at the town of Maalot on 15 May 1974 emphasizes the importance of speed
in hostage rescue. (16) Terrorists had taken a school and were holding the
children and teachers hostage. When the assault commenced, the terrorists began
killing the hostages. 22 children and teachers were killed and another 56
wounded. The point that will be made to the individual studying the scenario is
that in this type of operation, the difference between a dramatic success and a
disaster may be measured in just a few seconds.

As a research effort, the SEAL tactical Simulator (STS) would progress
from collection of suitable scenarios to development of tactical responses to
determining the relative merits of each option. Advanced development might
consist of adding combat video footage and a suitable computer interface. As
with medical casualty scenarios, plans developed in this type of an exercise
would often need to be modified in the field as a tactical situation unfolds
somewhat differently from the ones contained in the STS. Use of the STS to
train for tactical problems that emerge during a SOF operation is, however,
consistent with the guidance provided by General Peter Schoomaker,
Commander-in-Chief of the U.S. Special Operations Command, in his vision
statement: We must also have the intellectual agility to conceptualize
creative, useful solutions to ambiguous problems....This means training and
educating people how to think, not just what to think. This
project has been proposed as a candidate for funding through the USSOCOM Small
Business Initiative Research Program and is currently competing for funding in
FY01.

Acknowledgments

Special thanks to the many Special Operations physicians, corpsmen, PJs,
and medics who have assisted with this project. Thanks also to the SEAL line
officers who have contributed their time and support to the Tactical Medicine
for Mission Commanders project .

Bellamy RF: Presentation to the Joint Health Services Support Vision
2010 Working Group. September 1996.

Figure 1

Tactical Combat Casualty Care Objectives

Treat the casualty

Prevent additional casualties

Complete the mission

Figure 2

How People Die in Ground Combat

KIA

31%

Penetrating Head Trauma

KIA

25%

Surgically Uncorrectable Torso Trauma

KIA

10%

Potentially Correctable Surgical Trauma

KIA

9%

Exsanguination from Extremity Wounds

KIA

7%

Mutilating Blast Trauma

KIA

5%

Tension Pneumothorax

KIA

1%

Airway Problems

DOW

12%

(Mostly infections and complications of shock)

Figure 3

PREVENTABLE Causes of Death on the Battlefield

Bleeding to death from extremity wounds (60%)

Tension pneumothorax (33%)

Airway obstruction (maxillofacial trauma) (6%)

Figure 4

Phases of Care

Care under Fire

Tactical Field Care

Combat Casualty Evacuation (CASEVAC) Care

Figure 5

Care under Fire

Return fire as directed or appropriate

The casualty(s) should also continue to return fire if able.

Try to keep yourself from getting shot

Try to keep the casualty from sustaining additional wounds

Stop any life-threatening hemorrhage with a tourniquet

Take the casualty with you when you leave

Figure 6

Tactical Field Care

CPR should not be attempted on the battlefield for victims of blast
or penetrating trauma who have no pulse, respirations, or other signs of life.

The nasopharyngeal (tube in the nose) airway is the airway of first
choice for unconscious patients until the CASEVAC phase. Patients who are shot
in the face may require a surgical airway.

Progressive, severe respiratory distress in the setting of
unilateral blunt or penetrating chest trauma on the battlefield should result
in a presumed diagnosis of tension pneumothorax and that side of the chest
should be decompressed with a needle.

Casualties who have controlled bleeding without shock do not need
emergent IV fluid resuscitation.

Casualties who have had bleeding that is now controlled but who are
in shock should receive 1000cc of Hespan.

Casualties who have uncontrolled hemorrhage from penetrating wounds
of the chest or abdomen should receive no IV fluid in the field.

An exception to rule number 6 above is that casualties who have
uncontrolled hemorrhage from penetrating wounds of the chest or abdomen and
develop decreased mental status should either receive 1000cc of Hespan or be
fluid resuscitated to an end point of improved mentation.

Saline locks (plastic IV catheters without fluids attached) may be
used instead of IVs if fluid resuscitation is not required (for IV antibiotics
and morphine, if required).

Morphine is to be used IV (5 mg) instead of IM.

IV antibiotics should be used as soon as possible for patients with
penetrating abdominal trauma, grossly contaminated wounds, massive soft tissue
trauma, open fractures, or any patient in whom a long delay until definitive
treatment is expected.

Casualties should not be completely undressed for a secondary
survey in the field. Removal of clothing should be limited to that necessary to
expose known or suspected wounds.

Figure 7

Battlefield Triage

Control life-threatening bleeding

Disarm casualties as required

Establish airways (unconscious or respiratory distress)

Treat tension pneumothorax

Treat shock

Pain control

IV antibiotics

Figure 8

Urban Warfare Scenario 1  Fast Rope Casualty

16 man Ranger team  security element for building assault

70 foot fast rope insertion for building assault

One man misses rope and falls

Unconscious

Bleeding from mouth and ears

Taking fire from all directions from hostile crowds

Anticipated extraction by ground convoy in 30 minutes.

Figure 9

Urban Warfare Scenario 7 - Helo Hit by RPG Round

Hostile and well-armed (AK-47s, RPG) urban environment

Building assault to capture members of a hostile clan

In Blackhawk helicopter trying to cover helo crash site

Flying at 300 foot altitude

Left door gunner with 6 barrel M-134 minigun (4000 rpm)

Hit in hand by ground fire

Another crew member takes over mini-gun

RPG round impacts under right door gunner

Windshields all blown out

Smoke filling aircraft

Right minigun not functioning

Left minigun without a gunner and firing uncontrolled

Pilot

Transiently unconscious - now becoming alert

Co-pilot

Unconscious - lying forward on helos controls

Crew Member

Leg blown off

Lying in puddle of his own blood

Femoral bleeding

Figure 10

Tib/Fib Fracture on Parachute Insertion

- Twelve man SF team

Interdiction operation for weapons convoy

Night parachute jump from a C-130

4-mile patrol over rocky terrain to the objective

Planned helicopter extract near target

One jumper sustains an open fracture of his left tibia and fibula on
landing